单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,*,Xijing Hospital,Application of Percutaneous Coronary Intervention for Severe Calcification Lesions,严重钙化病变的PCI治疗,王海昌,第四军医大学西京医院心脏内科,陕西西安,Application of Percutaneous Co,1,严重钙化病变的pci治疗_ppt课件,2,Culprit and Healed Plaques in a Coronary Bifurcation,Coronary artery disease:Diffuse disease with a variable mix of stable,vunerable and culprit plaques,Fuster V,etal.JACC,2005:46:937-954,Culprit and Healed Plaques in,3,Epidemiology,由动脉粥样硬化导致，非退行性变,检出率存在显著的性别差异（女：男=1：2）,冠状动脉钙化计分随年龄增加呈增加趋势,冠心病危险因素与冠状动脉钙化密切相关,Bakdash 等报告非脂质性冠状动脉危险因素的数目与冠状动脉钙化沉积有关,Epidemiology 由动脉粥样硬化导致，非退行性变,4,29%of men and 15%of women who had no cardiovascular symptoms and exhibited no other common risk factors,had extensive coronary artery calcification.,European Heart Journal 25:4855,2004,29%of men and 15%of wo,5,Angiogram cannot detect calcifications,(CAG),Ultrafast computed tomography,(CT scanning),can measure arterial calcification(noninvasive),Intravascular Ultrasound,（IVUS）,Optical Coherence Tomography,(OCT),Diagnosis Methods,Angiogram cannot detect calci,6,严重钙化病变的pci治疗_ppt课件,7,严重钙化病变的pci治疗_ppt课件,8,Calcified coronary plaques imaged in vivo by optical coherence tomography(OCT)and intravascular ultrasound(IVUS),OCT,OCT,IVUS,IVUS,Calcified coronary plaques ima,9,Non-invasive Quantification for Calcified Lesions by CT Scan,Non-invasive Quantification fo,10,严重钙化病变的pci治疗_ppt课件,11,严重钙化病变的pci治疗_ppt课件,12,“中重度钙化（B型）病变是导致冠状动脉球囊成形术（PTCA）手术失败和血管急性闭塞的主要危险因素”,1988年ACC/AHA心血管诊治技术评价的报告,“中重度钙化（B型）病变是导致冠状动脉球囊成形术（PTCA,13,钙化病变介入治疗,单纯球囊扩张（PTCA）,成功率低（74），夹层率高，急性血管闭塞率高,球囊扩张支架术,可改善球囊扩张后的效果，提高成功率,严重钙化病变，单凭高压力植入支架，并发症高、,再狭窄率高,钙化病变介入治疗 单纯球囊扩张（PTCA）,14,钙化病变单纯PTCA的局限性,即刻效果,病变不能扩展和发生弹性回缩,再狭窄,多数研究没有显示钙化病变和PTCA后再狭窄之间的,关系,钙化病变单纯PTCA的局限性 即刻效果,15,Case 1(Balloon+DES),CAG,Case 1(Balloon+DES)CAG,16,Case 1(Balloon+DES),COSTLY!,3.5 hrs Operation time,Long X-Ray Exposure,6 Balloons,3 Guide Wire,3 Drug Elution Stents,Case 1(Balloon+DES)COSTLY!,17,Case 1(Balloon+DES),Pre-O,Final CAG,Case 1(Balloon+DES)Pre-O F,18,球囊成形术（PTCA）,冠脉夹层,发生率高，程度重。,部位在钙化与非钙化斑块的移行处，与球囊扩张过程中所产生的不均匀的剪切力有关,发生率从旋磨后的22增加到辅以球囊扩张后的77，夹层分离的部位也从钙化斑块的内（旋磨后）移至钙化斑块的外（PTCA后）,高压扩张，增加了球囊破裂和夹层分离的危险。,球囊成形术（PTCA）冠脉夹层,19,Initial Reaction:,Fear,Initial Reaction:Fear,20,Atherectomy,remove the plaque itself,cutting the soft plaque from the obstruction site,depositing it in a capsule which is then withdrawn.,Atherocathcourtesy Guidant,Atherectomy remove the plaque,21,Laser,Some catheters have also been fitted with special lasers which can photo-dissolve the tissue obstructing the arteries.,Laser catheter,准分子激光冠脉成形术（ELCA）,有报道称手术成功率较高。使钙化破裂而不是清除，对一些不能扩张的病变是有效的。术后再狭窄率较高为40,50。已经被旋磨取代,LaserSome catheters have also,22,Rotablator:,rotational atherectomy catheter,Rotablator,olive-shaped diamond burr,rotates at extremely high speed,Rotablator:rotational athere,23,Rotablator Syetem,驱动杆,导丝,钻石涂层磨头,1.25 mm-2.5 mm,(0.25 mm increments),鞘管,4.3 french O.D.,Rotablator Syetem 驱动杆导丝钻石涂层磨头,24,Rotablation,is recommended for fibrotic or heavily calcified lesions that can be wired but not crossed by a balloon or adequately dilated before planned stenting.One must know how to manage the complications inherent to rotablation.,AHA/ACC/FDA PCI Guideline,Rotablation is recommended for,25,钙化病变的分类,内膜面钙化,严重者影响球囊、支架的充分扩张，需要旋磨,外膜或斑块基底部钙化,造影显示明显，对PCI影响不大，不需旋磨,钙化病变的分类 内膜面钙化,26,DES时代钙化病变治疗的要点,钙化病变预扩张,支架完全覆盖病变,支架释放压16-18ATM,后扩张,血管内超声,DES时代钙化病变治疗的要点 钙化病变预扩张,27,STRTAS(Study To Determine Rotablator and Transluminal Angioplasty Strategy)初步结果显示，采用更大的磨头和较长的旋磨时间进行强烈的消蚀与更保守的消蚀方法相比，并没有改善即刻和远期效果。,旋磨支架（rotastent）能得到最大的管腔和最小的残余狭窄。,STRTAS(Study To Determin,28,钙化病变介入治疗的难点（I）,单纯依靠冠脉造影评价钙化程度欠准确,植入支架后的再狭窄率高,旋磨术适于内膜弥漫钙化病变，利于支架充分 植入，长期疗效更好，“无复流现象”增加,斑块切除术（DCA、TEC、ELCA）对钙化病变帮助较小,钙化病变介入治疗的难点（I）单纯依靠冠脉造影评价钙化程度,29,钙化病变介入治疗的难点（II）,直接支架植入应当慎重,支架通过困难，易造成支架脱落率增加,如用高压力（16atm）仍未使支架充分扩张者，,采用更高压力（20atm），仍可能不会达到满意,的支架扩张,支架不能充分扩张，亚急性血栓发生率增加,内膜夹层、撕裂率增加,球囊破裂、血管破裂、心包填塞增加,钙化病变介入治疗的难点（II）直接支架植入应当慎重,30,Case2：Severe Calcification and Balloon Suboptimal Dilation lead to Acute Stent Thrombosis,Male，57yrs,Smoking 30yrs，,Chest pain 3yrs，,Rest ECG：V1-V3 lead ST segment depression0.1mv,Cadiac Triponin T(-),Severe Calcification,Baloon dilation,Stenting,Case2：Severe Calcification and,31,Case2：Severe Calcification and Baloon Suboptimal Dilation lead to Acute Stent Thrombosis,4 days later!,Case2：Severe Calcification and,32,Female,，76,yrs,Exertional chest pain 8yrs,recurrent 10days,EF:40%,RCA1:5,0,，,RCA3:75,LAD,6,：75,7段90,with severe calcification,，,8:,50,，9:,50,；,LCX13:,100,14:,25%,15:,50,Case3：,Rotational Atherectomy for Severe Calcification,Female，76yrsCase3：Rotational,33,Cutting Balloon:2.5*10 (16ATM,20),Post dilate balloon,:,2.5,13 (18ATM,12),Case3：,Rotational Atherectomy for Severe Calcification,Cutting Balloon:2.5*10 (16,34,Guiding,：6F EBU3.5,Guide Wire,：S,tablizer/PT,2,MS,Bur,:,1.5mm,Rotor rate,：160000,rpm,Case3：,Rotational Atherectomy for Severe Calcification,Guiding：6F EBU3.5Guide Wire,35,2.5,24 TAXUS(10ATM,8),2.75,28,TAXUS(12ATM,7),Final CAG,Stenting,2.524 TAXUS(10ATM,